(2)Affiant
is the original ______________________ (consignee or consignor) named in
__________ (warehouse receipt) number ________________, dated____________
(month & day), _________ (year), issued by ____________________________________.

(3)On or
about __________ (month & day), ______ (year), affiant discovered that the
above mentioned document was __________ (lost or destroyed or stolen) in the
following manner: __________________________________________ (describe events
of loss).

(4)Affiant
requests delivery of the goods covered by the document even though surrender of
the document has not been made.Affiant
agrees to hold harmless and indemnify __________ (warehouseman) and any person
who suffers loss, damage, or injury by delivery of the goods arising out of the
delivery with non-surrender of the document.